8/12/2019 How Healthy is Your Diet-Questionnare

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How Healthy Is Your Diet?

Circle your answers after careful thought, then add up your points (numbers in parentheses).

1. How many fruits do you normallyeat each day (1/2 cup fresh or dried fruit, 1 medium piece,1 cup unsweetenedjuice)?

A. 0 (-2)B. 1 (0)C. 2 to 3 (+2)D. 4 or more (+3) (score) _____

2. How many vegetable servings do you normallyeat each day (1 cup leafy greens, 1/2 cup anyother veggie, raw or cooked)?A. 0 (-4)B. 1 (0)C. 2 (+1)D. 3 (+2)E. 4 or more (+3) (score) _____

3. How many different varieties of vegetables do you eat in a normal month?A. 2 or less (-4)B. 3 to 4 (0)C. 5 to 6 (+1)D. 7 to 8 (+3)E. 9 or more (+4) (score) _____

4. How many times do you eat dried beans or peas (legumes, lentils, chickpeas, kidney beans, greenpeas, etc.) in a normal week?A. 0 (-2)B. 1 to 2 (0)C. 3 to 4 (+1)D. 5 to 6 (+2)E. 7 or more (+3) (score) _____

5. How many times do you eat red meat in a normal week?A. 6 or more (-4)B. 4 to 5 (-3)C. 1 to 3 (-1)D. Less than once a week (+2)E. 0 (+3) (score) _____

6. How many times do you eat in a fast food restaurant in a normal week?A. 6 or more (-5)B. 4 to 5 (-4)C. 1 to 3 (-3)D. Less than once a week (-2)E. 0 (0) (score) _____

8/12/2019 How Healthy is Your Diet-Questionnare

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7. In a typical day, what do you drink mostoften?A. Soda (regular or diet) (-4)B. Caffeinated coffee or tea (-1)C. Decaffeinated coffee or tea (0)D. Milk or fruit juice (0)E. Herbal tea or water (+3) (score) _____

8. How many 12 oz. cans of soda do you drink in a normal day?A. 6 or more (-5)B. 4 to 5 (-4)C. 2 to 3 (-3)D. 1 (-2)E. Less than 1 (-1)F. 0 (0) (score) _____

9. How often do you eat fish in a typical week?A. Never (-2)B. Once (+1)C. Twice (+2)D. 3 to 5 times (+3) (score) _____

10. In a typical week, how often do you eat whole grains (100% whole grain bread, whole oats,brown rice, quinoa, whole rye crackers)?A. Never (-3)B. 1 to 2 times a week (-1)C. 3 to 4 times a week (0)D. 5 to 6 times a week (+1)E. 1 or more times a day (+3) (score) _____

11. How often do you eat sweets such as cookies, cakes, or ice cream?A. 1 or more times a day (-3)B. Every other day (-2)C. Twice a week (-1)D. Once a week (0)E. 2 to 3 times a month (+1)F. Rarely (+3) (score) _____

Your Total Score__________________

Scoring: 2228Great eating habits

1721Pretty good eating habits

1016Needs some improvement

9 or lessNeeds much improvement; try to change one habit at a time

From the Institute for Functional Medicine